July 6, 2012

Right, Almost Right, and Just Plain Wrong: Spelling (and Spacing) Variations

Filed under: punctuation,spelling,usage — amastyleinsider @ 11:09 am
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It is now the work of years for children to learn to spell; and after all, the business is rarely accomplished. A few men, who are bred to some business that requires constant exercise in writing, finally learn to spell most words without hesitation; but most people remain, all their lives, imperfect masters of spelling, and liable to make mistakes, whenever they take up a pen to write a short note. Nay, many people, even of education and fashion, never attempt to write a letter, without frequently consulting a dictionary.—Noah Webster1

The primary nonmedical/nonscientific dictionary used at JAMA and the Archives Journals is Merriam-Webster’s Collegiate Dictionary, and the medical/scientific dictionary of record is Dorland’s Illustrated Medical Dictionary. In the list given below, we show the preferred spelling of frequently misspelled scientific and nonscientific words as indicated by Webster’s and Dorland’s.

Whereas Webster’s shows equal or secondary variants in the entry “head,” Dorland’s uses a single term for the entry head but lists cross-references for variant spellings at the end of the entry for the preferred term. But note that Webster’s also often includes variant spellings in its entries (eg, aesthetic and esthetic). These “equal variants” are indicated by or. If they are given in alphabetical order, “they occur with equal or nearly equal frequency.” If they are given out of alphabetical order, but still joined by or, the first is slightly more common than the second. If they are joined by also, the word given second “occurs appreciably less often” than the first and is considered a “secondary variant.”

The front matter of Webster’s also notes: “Other spelling variants may be flagged with var with some further brief explanation, for example, metre … chiefly Brit var of meter.” Exception: Variant spellings that appear in direct, written (eg, published) quotations should not be changed to US variants.

To maintain consistency within their journals, the editors of JAMA and the Archives Journals prefer the first spelling of the entry of any given word.

Right and Almost Right

acknowledgment (equal variant, out of alphabetical order: acknowledgement)

aesthetic (secondary variant: esthetic)

breastfeeding (Webster’s: breast-feeding)

cutoff (as noun or adjective)

cut off (as verb)

distention (as given in Dorland’s; equal variant in Webster’s: distension)

judgment (equal variant, out of alphabetical order: judgement)

phosphorus (as noun)

phosphorous (as adjective)

sulfur (secondary variant: sulphur)

supersede (secondary variant: supercede)

Just Plain Wrong

accommodate (not accomodate)

ancillary (not ancilary)

arrhythmia (not arhythmia)

brussels sprouts (not brussel sprouts)

cholecystectomy (not cholecysectomy)

consensus (not concensus)

cribriform (not cribiform)

desiccate (not dessicate)

diphtheria (not diptheria)

dyspnea (not dysnea)

embarrass (not embarass)

erythematosus (not erythematosis)

Escherichia (not Echerichia)

fluorescent (not florescent)

fluorouracil (not flourouracil)

Haemophilus (not Hemophilus)

harass (not harrass)

hematopoietic (not hematopoetic)

Legionella pneumophila (not Legionella pneumophilia)

levothyroxine (not levothyroxin)

millennium (not millenium)

minuscule (not miniscule)

Neisseria gonorrhoeae (not Neisseria gonorrhea)

ophthalmology (not opthalmology)

Papanicolaou (not Papanicolou)

pertussis (not pertussus)

pruritus (not pruritis)

sagittal (not saggital)

sinusitis (not sinusitus)

sphygmomanometer (not sphygomamometer)

sulfide (not sulphide)

syphilis (not syphillis)

unwieldy (not unwieldly)

Now, this is nice and neat. But what if the 2 principal dictionaries (medical and nonmedical) differ on the preferred spelling of a word? Which to follow? We make such decisions on a case-by-case basis. For example, anti-inflammatory in Webster’s was chosen instead of antiinflammatory in Dorland’s because the former was considered to be expressed more clearly with a hyphen between the 2 i’s. Similarly, workup (as a noun, meaning a thorough evaluation to arrive at a diagnosis) was chosen over work-up. (But: Use work up as a verb!)

Spacing and punctuation (to hyphenate or not to hyphenate) add further questions of variation. These too are decided on a case-by-case basis. Below is a small sample of some of these decisions.

cost-effective, cost-effectiveness (not cost effective, cost effectiveness)

end point (not endpoint)

health care (not healthcare)

policy maker (not policymaker)

under way (not underway)

A final word to the wise: Until spell-checkers include a read-my-mind function, do not rely on them for solving spelling problems!—Roxanne K. Young, ELS

1. Webster N. An essay on the necessity, advantages, and practicality of reforming the mode of spelling and of rendering the orthography of words correspondent to pronunciation. In: Dissertations on the English Language: With Notes, Historical and Critical, to Which Is Added, by Way of Appendix, an Essay on a Reformed Mode of Spelling, With Dr. Franklin’s Arguments on That Subject. Boston, MA: 1789.

June 18, 2012

Bucking the “Trend” and Approaching “Approaching Significance”

Filed under: statistics — amastyleinsider @ 1:00 pm
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I believe we are on an irreversible trend toward more freedom and democracy – but that could change.

—Dan Quayle

In general usage, the concept of trend implies movement. Not only is this implied in its definitions, but the word can be traced to its Middle High German root of trendel, which is a disk or spinning top.1

In scientific writing, when is a trend not a trend? When it is not referring to comparisons of findings across an ordered series of categories or across periods of time. However, this and related terms are often misused in manuscripts and articles.

Most studies are constructed as hypothesis testing. Because an individual study only provides a point estimate of the truth, the researchers must determine before conducting the study an acceptable cutoff for the probability that a finding of an association is due to chance (the α value, most commonly but not universally set at .05 in clinical studies). This creates a dichotomous situation in interpreting the result: the study either does or does not meet this criterion. If the criterion is met, the finding is described as “statistically significant”; if it is not met, the finding is described as “not statistically significant.”

There are many limitations to this approach. Where the α level is set is arbitrary; therefore, in general all findings should be expressed as the study’s point estimate and confidence interval, rather than just the study estimate and the P value. Despite the limitations, if a researcher designs a study on the basis of hypothesis testing, it is not appropriate to change the rules after the results are available, and the results should be interpreted accordingly. The entire study design (such as calculation of the sample size and study power – the ability of a study to detect an actual difference or effect, if one truly exists) is dependent on setting the rules in advance and adhering to them.

If a study does not meet the significance criterion (for example, if the α level was set as < .05, and the P value for the finding was .08), authors sometimes describe the findings as “trending toward significance,” “having a trend toward significance,” “approaching significance,” “borderline significant,” or “nearly significant.” None of these terms is correct. Results do not trend toward significant—they either are or are not statistically significant based on the prespecified study assumptions. Similarly, the results do not include any movement and so cannot “approach” significance; and because of the dichotomous definition, “nearly significant” is no more meaningful than “nearly pregnant.”

When a finding does not meet statistical significance, there are generally 2 possible explanations: (1) There is no real association. (2) There might be an association, but the study was underpowered to detect it, usually because there were not enough participants or outcome events. A finding that does not meet statistical significance may still be clinically important and warrant further consideration.

However, when authors use terms such as trend or approaching significance, they are hedging the interpretation. In effect, they are treating the findings as if the association were statistically significant, or as if it might have been if the study had just gone a little differently. This is not justified. (Lang and Secic2 make the fascinating observation that “Curiously, P values never seem to ‘trend’ away from significance.”)

A proper use of the term trend refers to the results of one of the specific statistical tests for trend, the purpose of which is to estimate the likelihood that differences across 3 or more groups move (increase or decrease) in a meaningful direction more than would be expected by chance. For example, if a population of persons is ranked by evenly divided quintiles based on serum cholesterol level (from lowest to highest), and the risk of subsequent myocardial infarction is measured in each group, the researcher may want to determine whether risk increases in a linear way across the groups. Statistical tests that might be used for analyzing trends include the χ2 test for trend and the Cochran-Armitage test.

Similarly, a researcher may want to test for a directional movement in the values of data over time, such as a month-to-month decrease in prescriptions of a medication following publication of an article describing major adverse effects. A number of analytic approaches can be used for this, including time series and other regression models.

Instead of using these terms, the options are:

1. Delete the reported finding if it is not clinically important or a primary outcome. OR

2. Report the finding with its P value. Describe the result as “not statistically significant,” or “a statistically nonsignificant reduction/increase,” and provide the confidence interval so that the reader can judge whether insufficient power is a likely reason for the lack of statistical significance.

If the finding is considered clinically important, authors should discuss why they believe the results did not achieve statistical significance and provide support for this argument (for example, explaining how the study was underpowered). However, this type of discussion is an interpretation of the finding and should take place in the “Discussion” (or “Comment”) section, not in the “Results” section.

Bottom line:

1. The term trend should only be used when reporting the results of statistical tests for trend.

2. Other uses of trend or approaching significance should be removed and replaced with a simple statement of the findings and the phrase not statistically significant (or the equivalent). Confidence intervals, along with point estimates, should be provided whenever possible.—Robert M. Golub, MD

1. Mish FC, ed in chief. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

2. Lang TA, Secic M. How to Report Statistics in Medicine: Annotated Guidelines for Authors, Editors, and Publishers. 2nd ed. Philadelphia, PA: American College of Physicans; 2006:56, 58.


June 12, 2012

Apt, Liable, Likely

Filed under: usage — amastyleinsider @ 1:42 pm

Although these words are sometimes used interchangeably, particularly in infinitive constructions (apt to fall, liable to fall, likely to fall),1,2 using them interchangeably obscures subtle yet important distinctions between them.

Of the three, it seems that apt is the one most often used in its proper sense—perhaps because, unlike liable and likely, which both stress a potential consequence and thus are often confused, apt simply stresses inherent tendency (eg, “Elmer is apt to be a bit unsteady on his feet”).3 Also, whereas liable and likely refer to consequences and thus most commonly to conditions that will become manifest in the future, apt usually refers to conditions manifest in the past or present.1 In addition, some authorities hold that apt is perhaps most commonly used when referring to persons, although it can refer to nonhuman or inanimate subjects as well.1

So far so good—but, as alluded to above, tossing liable and likely into the mix can muddy the waters a bit. Both stress degrees of potential, but liable is the weaker of the two, used to stress possibility (eg, “Because Elmer is apt to be a bit unsteady on his feet, he’s liable to fall”) rather than outright probability.1 It has sometimes been held that liable should be used only when the subject of the sentence would face unpleasant consequences from the action expressed by the verb (“Because Elmer is apt to be a bit unsteady on his feet, he’s liable to fall and break a hip”).2 Certainly, of the three words under discussion, liable is the one most often taken as indicating that a consequence might be unpleasant or disadvantageous.3

Compared with liable, likely is a stronger term, used to stress probability (eg, “Because Elmer is apt to be a bit unsteady on his feet, he’ll likely fall if the steps are icy”) rather than mere possibility.1 However, unlike apt, likely used alone stresses no particular tendency in the subject that would enhance the probability of the outcome; moreover, unlike liable, it need not suggest the potential for an unpleasant consequence (eg, “Although Elmer is apt to be a bit unsteady on his feet, he’ll likely not fall, even if the steps are icy”).2

The bottom line:

● Looking for a word that stresses inherent tendency, particularly in a person? Use apt.

● Looking for a word that stresses possibility (as opposed to probability)—especially the possibility of some unpleasant consequence? Use liable.

● Looking for a word that stresses probability (as opposed to possibility), whether the perceived consequences be good or ill? Use likely.—Phil Sefton, ELS

1. Apt, liable, likely. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:56.

2. Liable. website. Accessed March 8, 2012.

3. Apt, liable, likely. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:48.

June 6, 2012

Acronym Morph: What’s an Editor to Do?

Filed under: acronyms — amastyleinsider @ 1:23 pm
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Sometimes we see things out of the corner of our eye. Then we think, “Did I really see that?” Lately, I’ve had that experience with certain acronyms morphing from all capital letters (eg, UNESCO) to initial capital letters (Unesco).

When acronyms drop their periods, I take it in without a second thought—it looks cleaner to me, someone used to the omission of periods in most acronyms from years of editing using the AMA Manual of Style. But this move from all-caps to only an initial cap jarred me, once I stopped and looked it in the eye. I was puzzled, too, by the pattern (or lack of one) behind this shift.

A little investigation seemed in order. The AMA Manual of Style distinguishes between acronyms and initialisms1 and indicates that periods are usually not used with them. But there is no mention of an all-cap or initial-cap style or preference. The Chicago Manual of Style2 notes that “Usage rather than logic determines whether abbreviations other than those standing for proper names are given in upper- or lowercase letters. Noun forms are usually uppercase (HIV, VP), adverbial forms lowercase (rpm, mpg). Note also that acronyms, especially those of five or more letters, tend to become lowercase with frequent use (NAFTA/Nafta, WASP/Wasp).” Special mention of this morph is made in discussing associations and the like: “Whether acronyms or initialisms…, such abbreviations appear in full capitals and without periods. Acronyms of five letters or more may be spelled with only an initial capital….” Chicago cites ERISA/Erisa (Employment Retirement Income Security Act) as an example.

Now we’re getting somewhere. Maybe there isn’t logic but maybe there is a pattern. Editors like both.

The Associated Press Stylebook3 advises, with regard to acronyms, “Use only an initial cap and then lowercase for acronyms of more than six letters, unless listed otherwise in this Stylebook or Webster’s New World College Dictionary.” So, it does seem to be related to length. How long is long enough to trigger this style change—5 letters? 6 letters?

This set me to thinking about things that began as acronyms and then morphed even further than becoming “proper nouns,” with an initial cap, to becoming “regular” words, all lowercase, as if they had never worn the guise of an acronym at all. The first such word that came to my mind was posh because I loved knowing that this word began as P.O.S.H. to stand for “port out, starboard home,” the location of the most expensive berths on luxury liners. However, I was chagrined to read in The Phrase Finder4 that this story was probably “dreamed up retrospectively to match an existing meaning.” It therefore is not an acronym but a backronym (a “reverse acronym,” a word or phrase constructed after the fact to make an existing word or words into an acronym”5).

What are other such words that we use as if they were fresh words but that began life as acronyms? I knew about snafu (“situation normal, all f—ed up”), which is so often used that most people don’t even know it had an earlier existence. Another one that, for some reason, I think most people do realize used to stand for something is scuba (“self-contained underwater breathing apparatus”). One that I see every day in reading medical journals that I hadn’t known started as an acronym is laser (“light amplification by stimulated emission of radiation”). Wonderful. Finding out the history of each of these acronyms is like opening a small treasure chest. Then there’s a host of others that all joined the language in the 1980s: yuppie (“young urban professional” or “young upwardly mobile professional”), buppie (“black urban professional”), guppie (“gay urban professional”), dink (“double income, no kids”). This is fun.

Some acronyms come from other languages: flak (from German: Fliegerabwehrkanonen, from Flieger flyer + Abwehr defense + Kanonen cannons).6 Some company names began as acronyms: Qantas began as QANTAS (Queensland and Northern Territory Aerial Services).

Getting back to the yen for logic and a pattern, with words there is a pattern that editors often chart, like physicians charting a patient’s temperature in a hospital record…watching to see when the temperature is right for them to jump in. Here the pattern is to begin with 2 separate words, then link them with a hyphen, then join them completely.

breast feeding→breast-feeding→breastfeeding

With acronyms it seems to be


With, sometimes, a brief detour to unesco.

For those of us who care about these details, we each need to decide (with words, with capital letters) when—watching the temperature—it’s time to jump in. For medical journals, vis-à-vis this acronym morph, we are going to continue to monitor the temperature before deciding to jump in for a swim.

Acronyms, backronyms. Words take us on a wonderful journey. Sometimes they are a journey in themselves.—Cheryl Iverson, MA

1. Iverson C, Flanagin A, Christiansen S, et al. AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007:441-442.

2. The Chicago Manual of Style. 15th ed. Chicago, IL: University of Chicago Press; 2003:559.

3. Christian D, Jacobsen S, Minthorn D, eds. The Associated Press Stylebook and Briefing on Media Law. Philadelphia, PA: Perseus Basic Books; 2009:2.

4. POSH. The Phrase Finder. Accessed June 4, 2012.

5. Backronym. Wikipedia. Accessed June 4, 2012.

6. Mish FC, ed in chief. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:475.

April 10, 2012

Ambiguous, Equivocal

Filed under: usage — amastyleinsider @ 9:43 am
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These words often are taken to mean the same thing—which in some contexts they indeed do. When used to refer to test results or experimental findings, for example, both words are properly used to indicate uncertainty, ie, that the findings can be understood in more than one way.

However, a distinction comes to bear when one is referring to statements, either written or oral. Although both words also can properly be used when referring to a statement subject to more than one interpretation, accepted usage holds that ambiguous is the proper choice if the resulting uncertainty seems unintentional1(p39) and that equivocal is the way to go if the uncertainty seems to have been intentionally introduced to confuse or deceive.1(p423) The deceptive intent is key, and it is worth noting that whereas the verb equivocate is an accepted word, ambiguate is not.

Deceptive intent might be inferred from the immediate context of surrounding statements. Often, however, intent is inferred from the larger context, ie, the history of the issue under discussion or the (perceived) character of the person making the statement. Given the latter means of inference, it is not surprising that the use of equivocal to refer to deceptive statements has been accepted since the late 1700s—about the time that the word also came to be commonly used to describe persons believed “[d]oubtful in character or reputation; liable to unfavorable comment or description; questionable; suspicious.”2(p527) Equivocal is still occasionally used when referring to such persons, but current usage, particularly in the social media, tends to favor terms somewhat more colorful.

Equivocal also can imply that a person has used ambiguous language in a qualifying way to avoid personal commitment to the statement made.1(p423) This meaning, however, although a bit more neutral than the meaning already noted, still hints at something less than savory. In short, although using ambiguous and equivocal interchangeably to describe a statement will be correct in some instances, writers tempted to use equivocal in place of ambiguous would do well to remember that the former has additional connotations often freighted with “nasty overtones.”3

Perhaps because clarity and certainty are seldom used for deceptive purposes, matters are less complicated in negative constructions: unambiguous and unequivocal both indicate that a test result or a statement has only one interpretation. However, because equivocal carries negative connotations, unequivocal is often used to emphasize a lack of deceptive intent.

As a side note, another word, unequivocable, has been used interchangeably with unequivocal since the early 1900s.2(p2166) How this monster came to be is a matter of some conjecture, but it likely arose either from innocent confusion over the proper spelling and pronunciation of equivocal or from a desire to use a loftier-sounding word (although it is difficult to imagine an instance in which unequivocal would not be lofty enough). In any case, unequivocable and its variants are often considered nonstandard.1(p1366)

The bottom line:

● Referring to test results or experimental findings having more than one interpretation? Ambiguous and equivocal are both correct, but it is worth noting that the latter can have negative overtones and is perhaps best avoided unless the reporting of results seems intentionally unclear.

● Referring to a statement having more than one interpretation? Remember that all equivocal statements are ambiguous, but not all ambiguous statements are equivocal. If the statement seems intentionally unclear with the goal of distancing or deceiving, use equivocal.

Unambiguous and unequivocal both indicate that something has only one interpretation, although when describing a statement unequivocal is sometimes used to emphasize an absence of deceptive intent.

Unequivocable, while found in some dictionaries, is often considered nonstandard and should probably be avoided.—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

2. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.

3. Ambiguous, equivocal. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:38.

March 27, 2012

A Few Thoughts on Fewer and Less

Filed under: usage — amastyleinsider @ 12:30 pm
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All of the usual English-language usage books seem so sure that they give little more than a compound sentence to explain that fewer should be used when referencing things that can be counted and less when referencing quantity or things that can be measured.

The AMA Manual of Style1 points out that the 2 words “are not interchangeable.” Then explains the difference by advising readers to “[use] fewer for number (individual persons or things) and less for volume or mass (indicating degree or value).” It offers the following examples: “Fewer interventions may not always mean less care” and “The authors evaluated fewer than 100 studies yet still reported more support for the conventionally prescribed therapy.” The entry is followed by a note that provides 2 more examples including parenthetical explanations:

spent less than $1000 (not: spent fewer than $1000)

reported fewer data (not: reported less data)

The Associated Press Stylebook2 entry says, “In general, use fewer for individual items, less for bulk or quantity” and provides the following examples, or should I say commands:

Wrong: The trend is toward more machines and less people. (People in this sense refers to individuals.)

Wrong: She was fewer than 60 years old. (Years in this sense refers to a period of time, not individual years.)

Right: Fewer than 10 applicants called. (Individuals.)

Right: I had less than $50 in my pocket. (An amount.) but: I had fewer than 50 $1 bills in my pocket. (Individual items.)

The Elements of Style3 elliptically warns, “Less should not be misused for fewer” with the following explanation. “Less refers to quantity, fewer to number. ‘His troubles are less than mine’ means ‘His troubles are not so great as mine.’ ‘His troubles are fewer than mine’ means ‘His troubles are not so numerous as mine.’”

A Writer’s Reference,4 a college handbook, is equally economical: “Fewer refers to items that can be counted; less refers to items that cannot be counted” followed by its example for usage: “Fewer people are living in the city” and “Please put less sugar in my tea.” (I’d rather that you didn’t put any sugar in my tea.)

But if the rule were so easy as these commonly used English-language usage references suggest, why are people confused?

If anything is certain about language, it is that nothing is certain: a truism that often frustrates my composition students, who simply want the answer when no one true answer exists. In the case of fewer and less, Webster’s Dictionary of English Usage5 and Fowler’s Modern English Usage6 support my position by telling an entirely different story about how to use less and fewer, with Webster’s devoting 3 and a third columns to it and Fowler’s devoting about 3 columns over 2 entries.

The former launches the alternate-usage discussion with a metaphoric clearing of its throat to suggest, however, that the general usage rule cited in most English-language reference texts “has only one fault–it is not accurate for all usage” and offers a rule amendment for using less:

less refers to quantity or amount among things that are measured and to number among things that are counted.

In other words, less can be used in both cases. Webster’s punctuates its point by saying the amended rule has actually reflected common usage for say “the past thousand years or so.” The general rule became established and embraced by most language scholars, so Webster’s theorized, from a 1770 comment about less made by Robert Baker in Reflections on the English Language. He wrote:

The word [less] is most commonly used in speaking of a Number; where I should think Fewer would do better. No fewer than a Hundred appears to me not only more elegant than No less than a Hundred, but more strictly proper.

Thus, a modest preference has become, as Webster’s points out, “elevated to an absolute status.” That transformation, the entry laments, may be due to the reluctance of “many pedagogues … to share the often complicated facts about English with their students.” In fact, Webster’s points to the Oxford English Dictionary as showing that “less has been used as countables since the time of King Alfred the Great.”

Although Fowler’s trends toward the generally accepted usage rule, it recognizes that perhaps the “complicated facts about English” should in fact be elucidated. As a means of clarification, it uses parts of speech to explain the usage differences. It says that “few and its comparative adj. fewer are used with countable nouns, i.e. with nouns that have both a singular and a plural form (book/books)…; or with collective nouns (fewer people…)” but, “[l]ess which is a comparative of little, is properly used with uncountable or mass nouns: in other words less refers to quantity and is the opposite of more (less affection, less power, less misery).” Furthermore, Fowler’s acknowledges when less can be used “idiomatically with plural nouns … esp. distances (it is less than seventy miles to London)” and the like.

In its final example in the few entry, Fowler’s notes the “regrettable” trend of “the use of less with an unprotected plural noun.”(That’s an expression that’s new to me.) One of the example sentences of that violation is

There will be less 100% loans about.

Don’t we all know that?—Beverly Stewart, MSJ

1. Iverson C, Christiansen S, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007.

2. Goldstein N, ed. The Associated Press Stylebook and Briefing on Media Law. New York, NY: Basic Books; 2007.

3. Strunk W, White EB. Elements of Style. 4th ed. New York, NY: Longman; 2000.

4. Hacker D. A Writer’s Reference. 6th ed. Boston, MA: Bedford/St Martin’s; 2009.

5. Webster’s Dictionary of English Usage. Springfield, MA: Merriam-Webster Inc; 1989.

6. Burchfield RW. Fowler’s Modern English Usage. 3rd rev ed. New York, NY: Oxford University Press; 2004.

March 19, 2012

Questions From Users of the Manual

Filed under: frequently asked questions — amastyleinsider @ 2:36 pm
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Q: A colleague and I both remember seeing in a style manual that an en dash should be used between 2 words of equal weight. However, we checked the AMA Manual of Style and saw that this was not a supported use of the en dash. Did this guideline appear in a former edition of the AMA Manual, or did we just pick this idea up from another source?

A: No, I don’t believe we have ever recommended an en dash between 2 words of equal weight. It is the hyphen that we recommend between 2 words of equal weight. See the middle of page 346 of the 10th edition, with the examples of “blue-gray eyes” and “blue-black lesions.” We recommend use of the en dash when the items on either side are not of equal weight (eg, one element consists of 2 words or a hyphenated word or a compound). There are examples at the bottom of page 352 and the top of page 353.

Q: Is it appropriate to abbreviate echocardiography as ECHO or echo in documents that describe the use of echocardiography during the treatment of various types of cancer?

A: We would be unlikely to abbreviate echocardiography (or any related term, such as echocardiogram) to ECHO or echo. We would spell this term out. Only in cases in which there are serious space constraints would we consider abbreviating this term (eg, in a large table), and then we would recommend expanding the abbreviation in a table footnote.

Q: Do you use Web site or website? Traditionally it has always been “Web site,” but in the past few years I have noticed a change to the more informal “website” in many publications. What is your recommendation?

A: On the home page of the AMA Manual, in the navigation bar, there’s a listing for “Updates.” If you take a look there, you’ll see that a relatively recent update (January 18, 2012) indicates that, as of that date, we began to prefer website to Web site.  Check “Updates” periodically to see if there are other, newer updates on material in the manual.

Q: I have a style question I cannot find addressed in your manual. On a manuscript I plan to submit to a journal, the corresponding author has moved since the manuscript was written and this author wants to indicate both her current and her former affiliation. Can you advise on how to phrase this information?

A: The answer to your question is in section 2.3.3 of the manual. See the relevant excerpt below:

The affiliation listed, including departmental affiliation if appropriate, should reflect the author’s institutional affiliation at the time the work was done. If the author has since moved, the current affiliation also should be provided.

Author Affiliations: Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. Dr Lloyd is now with the Department of Emergency Medicine, St Luke’s Hospital, Milwaukee, Wisconsin.

Cheryl Iverson, MA

March 12, 2012

Illicit, Elicit, Solicit

Filed under: usage — amastyleinsider @ 2:24 pm

“I am the offspring of illicit love.”1(p814)

“Only suffering… can elicit the perfumes of the soul.”1(p503)

“Henry had been soliciting the pope for some time, in order to obtain a divorce from Catherine of Aragon, his queen.”1(p1822)

Illicit, elicit, solicit. The above examples make it abundantly clear that these words have distinctly different denotations; yet they are often confused or misused, even by careful writers. In medical contexts, it is especially important to preserve the distinctions between them.

Illicit, denoting simply “not permitted; unlawful”2(p618) (and sometimes used colloquially to indicate naughty, unseemly, or immoral), has limited use in medical writing. For example, written materials might convey the risks associated with use of illicit drugs, discuss illicit relationships between researchers and industry, or report on the illicit trade in human body parts. Beyond such instances, however, the word does not often come into play.

Elicit, however, is another story. Denoting “to call forth or draw out (as information or a response)” or “to draw forth or bring out (something latent or potential),”2(p404) the word occurs frequently in medical contexts. It might be used in both senses regarding a patient–physician encounter: for example, a physician evaluating a patient’s pain will ask questions to elicit information about the characteristics of the pain (eg, location, nature, duration, exacerbating factors). From the patient’s perspective, that is the easy part, and patients might well wish this were the end of the matter; however, having thus elicited mere information about the patient’s pain, the physician then embarks on maneuvers expressly designed to elicit the real thing. In written materials covering the basic sciences and their clinical applications, elicit is perhaps most frequently used in the second sense noted above. For example,a writer might report that a new vaccine elicits a given immune response, describe pathological mechanisms that elicit organ damage, or present a theory of how a treatment might elicit changes in gene expression.

Even accomplished writers sometimes confuse the homophones illicit and elicit. However, these terms are easily distinguished from each other: illicit is always an adjective, whereas elicit is—in current usage—always a verb. (It also can help to remember that illicit denotes illegal; for the temperance-minded, the illicit distillation of spirits might also come to mind.)

Troublesome as homophones can be, however, sometimes near-homophones can be more so, especially when they are similar in meaning. For example, elicit and solicit—the latter most frequently used in medical contexts in the sense of “to approach with a request or plea”2(p1187)—are often used interchangeably, with solicit perhaps more frequently used in place of elicit.3 However, such use obscures an important distinction. The Oxford Dictionary of American Usage and Style perhaps explains this distinction most succinctly: “To solicit a response is to request it. To elicit a response is to get it.”3 Thus, in the patient–physician encounter alluded to above, the physician solicits information regarding the patient’s pain and then performs a physical examination to elicit and evaluate actual pain. The Oxford resource also points out an ambiguity that can arise when elicit and solicit are confused: “‘Sentient representatives expect the core group to solicit [read elicit?] response from about 4,000 people.’”3 In other words, will the group solicit responses from 4000 persons, or will the group approach a larger number of persons to try and elicit 4000 responses, knowing that some persons approached might not reply? In medical contexts, the distinction has obvious implications for reports of survey studies and possibly for discussions of power calculations in reports of clinical trials.

Three quick tips:

* Looking for an adjective to describe something as immoral, forbidden, or illegal? Illicit (think illicit = illegal) might be the ticket.

* Looking for a verb to convey the requesting of information? Consider solicit.

* Looking for a verb to convey the obtaining of information or the drawing forth of a response or change? Consider elicit (think elicit = get).—Phil Sefton, ELS

1. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.

2. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

3. Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000:309.

February 21, 2012


Filed under: statistics,usage — amastyleinsider @ 9:55 am
Tags: , ,

In medical contexts, incidence is most often used in its epidemiologic sense, ie, the number of new cases of a disease occurring over a defined period among persons at risk for that disease. When thus used, incidence may be expressed as a percentage (new cases divided by number of persons at risk during the period) or as a rate (number of new cases divided by number of person-years at risk).

Reporting several incidence values in the same sentence can nearly always be accomplished using the singular form (eg, “the incidence of nonfatal myocardial infarction during follow-up was 10% at 6 months, 19% at 12 months, and 26% at 18 months” or “the incidence of clinical stroke decreased significantly, from 7.6 to 5.3 per 1000 person-years in men and from 6.2 to 5.1 per 1000 person-years in women). However, in rare instances, sentence construction may necessitate the use of the plural, which of course is… what, exactly? The understandable urge to simply add an “s” at the end of the word to form the plural results in incidences — a form not found in most dictionaries and a clunker of a word if ever there was one. Writers wishing for a more mellifluous plural sometimes use incidence rates, a valid term but one perhaps best reserved for reporting incidence values expressed as actual rates rather than simple percentages. Moreover, incidences is sometimes used when reporting values either as percentages or as rates, in the latter case missing a valuable opportunity to emphasize that rates rather than percentages are being reported.

Thus, it is perhaps best to use incidences, awkward as it may be, when reporting multiple incidence values as percentages and incidence rates when reporting such values as rates, eg, “at first follow-up, the incidences of falls resulting from frailty, neuromuscular disorders, or improper use of mobility devices were 15% (95% CI, 10%-20%), 12% (95% CI, 7%-17%), and 12% (5%-19%), respectively” or “the incidence rates for falls resulting from frailty, neuromuscular disorders, or improper use of mobility devices were 5.1, 6.3, and 4.6 per person-year, respectively.” Incidentally, these 2 examples report occurrences (falls) rather than diseases or conditions, and so represent 2 instances reporting the incidence of incidents.

To further muddy the waters, incidence is sometimes confused with prevalence, defined as the proportion of persons with a disease at any given time (ie, total number of cases divided by total population). Thus, whereas incidence describes how commonly cases are diagnosed, prevalence describes how widespread the disease already is; on a more personal level, incidence describes one’s risk of developing the disease, whereas prevalence describes the likelihood that one already has it. The confusion between the terms is perhaps attributable to the occasional use of prevalence in place of incidence in the study of rare, chronic diseases for which few newly diagnosed cases are available; however, this circumstance is unusual, and incidence and prevalence should always be distinguished from one another and used appropriately. (See also §20.9, Glossary of Statistical Terms, in the AMA Manual of Style, p 872 in print.)

Whereas prevalence is often used in general contexts to indicate predominance or general acceptance, the circumstances calling for the use of incidence in general contexts are quite few and become fewer still when one takes into account that incidence is often used when incidents (the simple plural of incident) or instance (again denoting an occurrence) would be the better choice. Perhaps incidents or instances was intended but never made it to the page — as is so often the case with homophones and near-homophones, even the careful writer who usually would not confuse incidence, incidents, and instance might one day look back over a hastily typed passage only to see that a wayward incidence has crept in; if the passage is hastily edited to boot, the error might well go unnoticed until the passage is in print and a discerning reader takes pains to point it out in a letter or e-mail. The plural form, incidences, has virtually no use outside of the epidemiologic discussed above, although it has been used to subtly disorienting effect by translators rendering the Kafkaesque works of Russian writer Daniil Kharms (1904-1942) into English, most notably when rendering the 1-word title of Incidences, Kharms’ 1934 collection of absurdist critiques on life in the Soviet Union under Stalin. However, writers who are not political dissidents aiming for absurdist effect — presumably all medical writers — would do well to proofread carefully and often. — Phil Sefton, ELS

February 13, 2012


Filed under: usage — amastyleinsider @ 1:53 pm
Tags: ,

How much can one trust a curmudgeonly English composition teacher who terrorized his early 20th-century Cornell students? How relevant are his grammatical admonitions today? With little else to support my inclination to remove the word respective or its adverb partner respectively and unite the string of data points with what they modify, I find the barking rules of E. B. White’s college rhetoric teacher William Strunk Jr calming.

Based on White’s description of his teaching style in the introduction of Elements of Style,1 I can assert with some certainty that had Strunk found himself an adjunct English composition instructor today, “lean[ing] forward over his desk, grasp[ing] his coat lapels in his hands, and in a husky, conspiratorial voice, say[ing], ‘Rule Thirteen. Omit needless words! Omit needless words! Omit needless words!’” it might not go over so well with today’s sensitive students. The style of this widely emphatic man who barked writing rules during his lectures lasted a lifetime for White. Now about 100 years later, such barking would likely cause a rush to the dean’s office to do something about this brazen man’s approach to teaching. He would simply not be asked back the next semester because the trend today is for warm-hearted English comp teachers to create a safe environment in which students can write without becoming immobilized by gruff commands. So in as much as the style of teaching would end a career today, should one conclude that Strunk’s rules for writing have become as out of date as his approach to teaching them?

Several months ago, after reading White’s delightful 1972 homage to Strunk, I flipped through some of the commands and came upon a piece of advice that lifted me out of my self-doubt and emboldened me not to give up on eradicating the use of the word respective. Unlike the image of Strunk as confident, I am not so. I am one who will eventually cave on a rule, especially if I’m the only one defending it. For example, the use of healthful over healthy when describing behavior that leads to my good health—I have let it go. If a manuscript comes in describing eating fruit as healthy, I will let it stand and not change it to healthful.

Yet, when I see in almost every article that I edit a string of numbers followed by a list of items each number describes covered by respectively at the end of the sentence, my eyes cross. I become disheartened. As I push back my sleeves to match the experimental treatment groups with the values to describe the efficacy of a treatment, I sometimes wonder whether it is worth the effort to set up the parallel structure and the repletion of words to make the match. I sigh and do it, hoping not to offend the author.

Copyediting is a solitary experience that doesn’t often allow for consensus about the rules because, as they say, much of it is a matter of preference. But when one’s eyes land on a sure-footed confirmation about a problem that niggles and nags almost every day of my work life, I must rejoice, which is exactly what I did when my eyes fell to Strunk’s simple exhortation:

Respective, respectively. These words may usually be omitted with advantage.

My heart leaped. I am not alone! Strunk follows his simple rule with an example that justifies my applying it to scientific editing.

The mile run and the two-mile run were won by Jones and Cummings, respectively.

The mile run was won by Jones, the two-mile run by Cummings.

Look at that. The second example has fewer words.

The true purpose of writing is to be clear and not make the reader work too much. As the attention span of the reader decreases by the second, making them match numbers to words 3 lines down gives the reader little reason to continue. In light of today’s hot-footed race against time, I say Strunk is more relevant now than ever. White was right when he wrote in 1979:

“All through The Element of Style one finds evidences of the author’s deep sympathy for the reader. Will felt that the reader was in serious trouble most of the time, a man floundering in a swamp, and that it was the duty of anyone attempting to write English to drain this swamp quickly and get his man up on dry ground, or at least throw him a rope.”

Beverly Stewart, MSJ

1. Strunk W Jr, White EB. Elements of Style, 2nd ed. New York, New York: Macmillan Publishing Co; 1972.

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